their interventions. In doing so, several water quality test parameters were also included at different stages between water collection to water consumption (Roberts et al., 2001;
Elsanousi et al., 2009). However, no huge shift from the existing water sources was noted in any of the studies, instead the authors tried to adapt with the existing water sources by introducing some additional stages for water treatment and storage practices.
In order to measure the impacts of the interventions, self-reporting has been chosen as the most convenient measure for all the articles. Here, the reporting frequency and mechanism varied from one to other. This study aimed to explore a wide variety of health outcomes without any specific focus on diarrheal diseases. But at the later stage of the study, it was found that none of the suitable articles addressed any health outcome other than diarrheal diseases. Also, most of the studies tried to minimize the effects of confounding variables and bias by adopting certain measures in some extent; but none of them specifically listed the type of biases reduced while conducting this study. Studies, especially those based on any critical context, i. e. humanitarian emergencies, often limits the scope to list all the biases, since many programs run in this specific contexts without proper planning and documentation (Ruby et al., 2015). It causes difficulties to track and list the effects of factors.
Besides, the methodology and findings of the chosen articles covered multiple aspects with detailed description. The study designs of the chosen articles were not identical at all and the methodologies contextualized as needed. This is why different types of sampling procedure and study types have been noted in the tables of the result section. The findings were also discussion using the concepts of prevalence, incidence, adjusted risk ratio and other terminologies. These are the commonly reported parameters for any diarrheal disease (Agustine et al., 2013). Also, other types of analysis were also conducted using statistical software as elaborated in the summary sections. In brief, all the adopted interventions were
found to be useful in uplifting the status of the health outcomes, since the episodes of diarrheal diseases reduced drastically for all the introduced interventions. This is useful to predict the effectiveness of different interventions for other humanitarian emergency crisis context.
5.2 Comments on Study Quality Assessment
Study quality of the chosen articles have been rated using standardized CONSORT and STROBE checklist and study quality for all the chosen articles lie below 80%. Since both of these guidelines are widely adopted to improve the quality of study design and findings organization, it is definitely necessary to include the aspects mentioned in the checklists for producing a good quality article (Bolignano et al., 2013). Besides, Auerbach (2016) and Vandenbroucke (2009) suggest that while designing and writing papers for any randomized / non-randomized trial, CONSORT checklist should be followed and for observational studies, STROBE checklist should be followed. The authors of the selected articles could have gone through these checklists to enhance their study quality. This is also okay to go through other such well-known checklists or expanding the CONSORT-STROBE checklists as needed.
This will not only improve the study quality but also cover a wider scale of discussions in a more organized manner. Here, since the graded percentages for most of the selected articles are not up to the mark (<80%), it is evident that the amount and quality of studies related with this specific topic is inadequate. This indicates the need for higher priority in this sector through future researches.
5.3 Limitations of the Study
The thesis focuses on an important area of public health studies, drinking water interventions, in an extremely critical situation, humanitarian crisis contexts happening around the globe.
However, while conducting the study, several limitations have been identified which have
been briefly discussed below.
Firstly, in terms of literature searching, the study used limited number of databases concerning the accessibility using Independent University Bangladesh’s library database.
Though the databases searched were good enough to choose seven final articles following all the stages of choosing articles, it would be more resourceful if some more databases
(especially, databases focused on public health studies) were accessible using IUB’s library domain. Some of such databases could have been Medline, Scopus, Embase etc. However, to overcome this limitation in some extent, huge time was put on hand-searching the articles in google scholar and PubMed which helped to bring about ample amount of relevant articles.
Besides, the study holds very strict restrictions associated with exclusion and inclusion criteria. Especially, choosing only quantitative studies that links drinking water interventions with health outcomes limited the scope of choosing the finally selected articles. It is because the criteria narrowed down the number of suitable articles. Also, the study context,
humanitarian emergencies, is also quite critical for researchers to implement this specific type of study according to the thesis’s selected criteria. This caused some challenge in identifying the most suitable articles.
Other than this, the variation of health outcomes addressed in this study is also very low, since almost all the finally-selected studies focused on diarrheal diseases. Thus, this thesis is unable to provide much knowledge on how drinking water interventions can contribute to other health outcomes, especially for mortality, morbidity and non-communicable diseases.
These are the major limitations of this study which should be overcome in future researches.
CHAPTER 6: CONCLUSION & RECOMMENDATIONS
This systematic review explored how different drinking water interventions helped to
promote health outcomes in humanitarian emergencies. Through systematic identification of studies, the review conducted an in-depth analysis on the selected study and analyzed the effectiveness of interventions to reduce diarrheal episodes mostly. At the same time, study quality was analyzed to assess the quality of existing knowledge in this regard. Findings show positive outcomes brought by different interventions which reduced the occurrence and episodes of diarrheal diseases with statistical significance. But the overall quality of the existing studies was not found to be much satisfactory while testing with CONSORT and STROBE checklist. The checklist identifies several areas where the articles should improve.
Besides, more sophisticated reduction in the effects of bias and confounding factors is also necessary for most of the selected articles. However, future research should be more focused on bridging the effectiveness of drinking water interventions with health outcomes other than diarrheal episodes and it will be a noteworthy addition to the co-currently existing literatures.
In doing so, more collaborative research should also be planned including professionals with specializations on emergency contexts, public health and water technologies. In addition, the following recommendations can be suggested based on the outcomes of the study.
a) Studies on drinking water interventions should incorporate the public health aspects.
While doing literature searching, many studies were found bridging no connection with health aspects. This situation should be changed to properly draw links between interventions and corresponding health outcomes. In this regard, non-communicable diseases and non-diarrheal diseases should be prioritized, since there is hardly any good research on these health concerns connecting with drinking water interventions adopted during emergency crisis context.
b) During humanitarian emergencies, evidence on epidemiological data collection and storage is highly inadequate. This is the reason the stakeholders associated with humanitarian crisis management cannot plan and prepare better using the experience and knowledge from former crisis. As a result, outbreak of diarrheal diseases and child mortality is quite common incidents for many humanitarian emergencies. This situation should be changed through proper knowledge documentation, training and contextualized supports derived from past experiences.
c) Identification on all the different ways of bias is also necessary in such studies.
Situation during humanitarian emergencies change quite suddenly and it is often difficult to keep track on all the things happening in such cases. Yet, the researchers should carefully reduce the effects of bias so that more appropriate linkages can be drawn between drinking water interventions and health outcomes. Some of the selected studies in this review also lag behind in this matter.
CHAPTER 7: REFERENCES
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CHAPTER 7: ANNEXURE ANNEX A
Table 8: PRISMA Checklist Section
and Topic Item # Checklist item
Location where item is reported TITLE
Title 1 Identify the report as a systematic review.
ABSTRACT
Abstract 2 See the PRISMA 2020 for Abstracts checklist.
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of existing knowledge.
Objectives 4 Provide an explicit statement of the objective(s) or question(s) the review addresses.
METHODS Eligibility criteria
5 Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses.
Informatio n sources
6 Specify all databases, registers, websites, organisations, reference lists and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted.
Search strategy
7 Present the full search strategies for all databases, registers and websites, including any filters and limits used.
Selection process
8 Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.
Data collection process
9 Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.
Data items 10a List and define all outcomes for which data were sought. Specify whether all results that were
compatible with each outcome domain in each study were sought (e.g. for all measures, time points,
analyses), and if not, the methods used to decide which results to collect.
10b List and define all other variables for which data were sought (e.g. participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information.
Section
and Topic Item # Checklist item
Location where item is reported Study risk
of bias assessment
11 Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.
Effect measures
12 Specify for each outcome the effect measure(s) (e.g.
risk ratio, mean difference) used in the synthesis or presentation of results.
Synthesis methods
13a Describe the processes used to decide which studies were eligible for each synthesis (e.g. tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item
#5)).
13b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.
13c Describe any methods used to tabulate or visually display results of individual studies and syntheses.
13d Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical
heterogeneity, and software package(s) used.
13e Describe any methods used to explore possible causes of heterogeneity among study results (e.g. subgroup analysis, meta-regression).
13f Describe any sensitivity analyses conducted to assess robustness of the synthesized results.
Reporting bias
assessment
14 Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases).
Certainty assessment
15 Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome.
RESULTS Study selection
16a Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.
16b Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.
Study characterist ics
17 Cite each included study and present its characteristics.
Risk of bias in
18 Present assessments of risk of bias for each included study.
Section
and Topic Item # Checklist item
Location where item is reported studies
Results of individual studies
19 For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g.
confidence/credible interval), ideally using structured tables or plots.
Results of syntheses
20a For each synthesis, briefly summarise the
characteristics and risk of bias among contributing studies.
20b Present results of all statistical syntheses conducted. If meta-analysis was done, present for each the summary estimate and its precision (e.g. confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect.
20c Present results of all investigations of possible causes of heterogeneity among study results.
20d Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results.
Reporting biases
21 Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed.
Certainty of evidence
22 Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed.
DISCUSSION
Discussion 23a Provide a general interpretation of the results in the context of other evidence.
23b Discuss any limitations of the evidence included in the review.
23c Discuss any limitations of the review processes used.
23d Discuss implications of the results for practice, policy, and future research.
OTHER INFORMATION Registratio
n and protocol
24a Provide registration information for the review, including register name and registration number, or state that the review was not registered.
24b Indicate where the review protocol can be accessed, or state that a protocol was not prepared.
24c Describe and explain any amendments to information provided at registration or in the protocol.
Support 25 Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review.
Competing interests
26 Declare any competing interests of review authors.
Availabilit y of data,
27 Report which of the following are publicly available and where they can be found: template data collection
Section
and Topic Item # Checklist item
Location where item is reported code and
other materials
forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review.
ANNEX B
Table 9: CONSORT Checklist & Paper Grading CONSORT Item
No Recommendation ID 3 ID 1
(X) (X)
Title and abstract
Title and
abstract 1
How participants were allocated to interventions (eg, “random allocation”,
“randomised”, or “randomly
assigned”). X X
Introduction
Background 2
Scientified background and
explanation of rationale. X X
Methods
Participants 3
Eligibility criteria for participants and the settings and locations where the
data were collected. X
Interventions 4
Precise details of the interventions intended for each group and how and
when they were actually administered. X X Objectives 5 Specific objectives and hypotheses. X X
Outcomes
Clearly defined primary and secondary outcome measures and, when
applicable, any methods used to enhance the quality of measurements (eg, multiple observations, training of
assessors, etc). X X
Sample Size 7
How sample size was determined and, when applicable, explanation of any
interim analyses and stopping rules.
Randomisation
Sequence
generation 8
Method used to generate the random allocation sequence, including details of any restriction (eg, blocking,
stratification). X
Allocation
concealment 9
Method used to implement the random allocation sequence (eg, numbered containers or central telephone), clarifying whether the sequence was concealed until interventions were
assigned.
Implementation 10
Who generated the allocation
sequence, who enrolled participants, and who assigned participants to their
groups.
Blinding
(masking) 11
Whether or not participants, those administering the interventions, and those assessing the outcomes were
aware of group assignment. If not, how